Dr Noreen Chan, Senior Consultant in Palliative Medicine at NUHS, discusses the importance of palliative care in the emergency department.
 Dr Noreen Chan
Senior Consultant in Palliative Medicine, Department of Haematology-Oncology, NCIS, NUHS
Assistant Professor (Clinician-Educator Track), Department of Medicine, National University of Singapore
"Young physicians entering emergency medicine may envision spending their careers mending trauma victims and restarting stuttering hearts but soon find that they spend as much or more time treating chronically ill patients who cycle in and out of the ED with high symptom burdens and a grim trajectory that no one has stepped up to explain.”     
So wrote Joanne Kenen in the Annals of Emergency Medicine in 2010. She was describing the global demographic imperative of ageing societies (what we term “the silver tsunami”), where increasing numbers of people with chronic progressive illnesses will go to the emergency department (ED) with life-threatening conditions. Some will not survive, even with aggressive treatment.
For the frailest, sickest patients who are nearing the end of life, the traditional “all guns blazing” approach is often neither appropriate, nor even desired by patients and families. This is where palliative approach in emergency medicine comes in.
Figures showed that in the National University Hospital (NUH) in 2011, a quarter of deaths (about 400) were in the ED. Three times that number were admitted to the general ward and died, with 12 per cent of them in the first 24 hours. This means that large numbers of patients the ED sees each day are near end of life, and some are actively dying. The irony is until a few years ago, there was no formal training in palliative care in Emergency Medicine.
End-of-life care can be challenging at the best of times, and in the time-pressured environment of the ED, it might seem easier to prioritise the more familiar cases of traumatic injuries or cardiovascular collapses, where one can operate in protocol-mode until the patient stabilises, or dies.
Yet there are many similarities between Emergency Medicine and Palliative Care for dying patients. Working in teams, identifying and solving problems, swift and decisive action are hallmarks of what we do. We act quickly and we need to get it right the first time, because there is no luxury of a second chance.
The ED staff at NUH recognised that change was necessary, and identified three areas for training and improvement: Communication, particularly around goal-setting and decision-making; management of symptoms like pain and breathlessness, and dignified care of the dying patient.
In addition, there was consultation and discussion about the many day-to-day practicalities, including ethical and medicolegal issues faced on the ground. For example, how much priority do you place on family’s wishes as opposed to patient’s previously expressed views, when the patient is acutely ill and unable to communicate?
There have been many challenges along the way - “I didn’t sign up for this”,“I don’t know how to handle the families”, “the primary doctors should have had this discussion long ago” -  none more so than how to change mindsets and culture.
It is not a matter of doing everything or doing nothing, but doing what is right. And what is right for the dying patient is what respects their values, prioritises comfort and dignity, and brings consolation and meaning to those who will be left behind.
Dr Noreen Chan spoke at the International Resuscitation Science Symposium, held on 27-28 Feb at Academia, SGH campus.